The impact of home care nurse staffing, work environments and ...

The Impact of Home Care Nurse Staffing, Work Environments and Collaboration on Patient Outcomes Phase II: Policy Implications for Ontario

March 24, 2015

Table of Contents Introduction and Context The present study

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The Policy Landscape Ontario context Challenges in Ontario Home Care Safety and Quality Outcomes The Home Care Patient Experience Scope of Practice Issues Structures and Processes of Delegation, Teaching & Assignment

5 5 7 8 11 13 17

Implications for Policy Decision Makers Next Steps

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Appendices Appendix A | Key Terms and Definitions Regulated Care Provider Unregulated Care Provider Assignment Teaching Delegation Other Key Terms Appendix B | Recommendations of the pan-Canadian home care safety report 1. Organizations 2. Policymakers 3. Researchers Appendix C | Summary of barriers and enablers to optimal scope of practice identified by Canadian Academy of Health Sciences Appendix D | CCAC Personal Support and Homemaking Tasks CCAC Personal Support and Homemaking Tasks

22 22 22 22 22 22 23 23 25 25 25 25

Resources Permissions References

31 31 31

26 27 27

List of Figures Figure 1. Reasons for home care referral in Canada ......................................................... 4 Figure 2. Commonwealth Fund 2014 rankings of health systems performance ................ 8 Figure 3. College of Nurses of Ontario client continuum ................................................. 14 Figure 4. College of Nurses of Ontario environment continuum ..................................... 15 Figure 5. College of Nurses of Ontario Decision tree: Making decisions about activities performed by unregulated care providers (UCPs) ................................................... 17 Figure 6. Steps and factors in assignment of home care providers ................................. 18

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The impact of home care nurse staffing, work environments and collaboration on patient outcomes Policy Implications for Ontario

Introduction and Context For more than a decade, health systems transformation efforts across Canada have focused on identifying strategies to provide a wider range of services to a growing population with evolving health needs — all while juggling demands to contain costs and improve safety and quality. In all those efforts, home care has emerged as an attractive solution to delivering a broad range of cost-effective acute, chronic, longterm and palliative care services. Enabled by technological advances, increasingly complex technical care can be delivered in home settings, and most patients seem to prefer the comfort and familiarity of their own homes to care in institutional settings.1 Home care holds significant promise as a long-term strategy to manage the costs of providing effective, satisfying services to the growing number of Canadian seniors living into very old age, even those with complex co-morbid chronic diseases.2 With that said, home care is not just for seniors: Among the 2.2 million Canadians who received home care in 2012, 29% were under the age of 45 — slightly more than those aged 75 and older (27%).3 Also home care is not just about caring for those with noncommunicable or chronic physical conditions; notice in Figure 1 that the two most common reasons for home care utilization were for mental health conditions and traumatic injury. 4

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Figure 1. Reasons for home care referral in Canada Most Canadians needing home care first receive help from family and friends (88%).5 Half of these also need outside help consisting of services typically delivered by a mix of regulated providers such as registered nurses (RNs), registered (or licensed) practical nurses (RPNs) and physiotherapists, as well as unregulated providers including personal support workers (PSWs) and other support services.i However, as essential as it has become, the structure and delivery of home care reflect a complicated patchwork of policy and program responses across the country. Who receives care and how care happens (for example how it is decided which providers will deliver what aspects of care and how they all communicate and coordinate) is not uniform or consistent across jurisdictions. Efficiency, safety and quality outcomes are inconsistently demonstrated and understood. It would be prudent to close those gaps before we invest further in expanding home care programs.

i

See Appendix A for definitions of terms.

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The present study The purpose of the present study is to understand how nursing care is structured in home care by examining the roles of RNs, RPNs and PSWs in the planning, management and delivery of home-based nursing care. 

Phase I was exploratory in nature and included a jurisdictional scan to identify current legislation, position papers and policy documents influencing structures of home-based nursing care. Additionally, literature related to relationships between structures of home-based nursing care and home care client outcomes were reviewed.



Phase II involves analysis and application of Phase I findings to the Ontario context. This paper focuses on study Phase II – an exploration of how jurisdictional scan findings may be applied to the Ontario situation as well as identification of gaps in knowledge and practice issues.

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Phase III includes primary research to evaluate how current Ontario legislation and policies are manifested in practice and how nurses and clients are affected by these structures of home-based nursing care.

The Policy Landscape Ontario context Home care, like all other health care services in Canada, reflects the federated governance of the country wherein the delivery of services and regulation of health professionals falls to the individual provinces and territories. Also mirroring other aspects of health care, home care in Ontario includes a mix of for-profit and not-for-profit providers who may both be contracted by governments or health authorities to provide publicly funded services to patients, or who may be directly engaged and paid out of pocket by private individuals. Many different forms of home care programs exist, with different providers delivering 5

different services across the country. Even within jurisdictions, access to a level playing field of services is not guaranteed. This analysis is limited to publicly funded home care services authorized, coordinated and contracted by Ontario’s 14 Community Care Access Centres (CCACs). The federated model also underpins the legislative and regulatory mix that characterizes the different regulated categories of nurses that are based on educational preparation. Across the 13 provincial and territorial jurisdictions, there is no common legislative or regulatory framework for any of Canada’s four regulated nursing categories (RNs, RPNs, nurse practitioners, and in the case of the four western provinces, registered psychiatric nurses.) Legislated titles and their meanings vary across borders, and terminology used to describe the regulated scopes of practice of the various categories is as broad and diverse as the country itself. The education level required to enter practice for RNs — a baccalaureate degree — is common to all jurisdictions except the province of Quebec, but the curriculum delivered to attain that degree may have little common framework or pedagogy. For RPNs (LPNs in all jurisdictions other than Ontario), the education level for entry to practice varies widely across the country. Within Ontario, a two-year diploma is required of RPNs. In Ontario, RNs and RPNs are co-regulated by the College of Nurses of Ontario (CNO).ii As shown in Table 1, the CNO reported that from among all nurses working in community settings, CCACs employed 4,028 RNs and 581 RPNs in 2014.6 An additional 3,010 RNs and 2,737 RPNs identified themselves as being employed as visiting nurses in community settings.

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Rounded numbers employed in nursing in Ontario: 96,000 RNs, 36,000 RPNs, and 2,200 nurse practitioners.

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Table 1. RNs and RPNs employed in home care in Ontario in 20137 Regulated category

All community Nurses

Employed by CCAC

Employed as a visiting nurse

RN

22,647

4,028

3,010

RPN

8,423

581

2,737

If the titles, roles, scopes and responsibilities of the regulated categories of nurses are not consistently defined, then the state of things for PSWs across Canada is many times more complicated. Standards for minimal training to work as a PSW are just starting to emerge, and there is no regulation of, or accord on the role title, responsibilities or accountabilities. The Personal Support Network of Ontario states that PSW training must be a minimum of 500 hours in length (600 hours to work in long-term care) and must include a minimum of 225 hours of classroom theory, 265 hours of practical placement experience, and 10 hours of evaluation.8 There is no provincial or national PSW certification examination despite the claims of some private career colleges. Voluntary PSW education program accreditation has begun to roll out in Ontario. Approximately 34,000 PSWs are employed in Ontario home care, and they deliver health and home support services under the direction of RNs and/or RPNs. The nursePSW relationship warrants particular attention given that PSWs provide up to 80% of formal home care services across Canada9 and they do so under the direction of nurses.

Challenges in Ontario Home Care Similar to growth in other jurisdictions, the Government of Ontario has “more than doubled funding for home care since 2003” and has plans to expand further to “provide increased access to services for those who need them most including nursing, personal support, home making and assistive devices, as well as increasing the use of technologies such as tele-homecare.”10 Before further expansion occurs however, effectiveness, safety and quality outcomes in Ontario home care demand further investigation. 7

Safety and Quality Outcomes According to the latest update of the Commonwealth Fund international rankings, Canada’s health care system continues to lag on performance relative to spending, especially in measures of quality, including safety, coordination and patient centeredness (see Figure 2).11 Despite this conclusion, in Ontario more than 90% of patients reported satisfaction with their home care in 2013/2014, and the same number received the required nursing care within five days of it being authorized. 12 This delay was longer for patients with complex needs waiting for personal support services. Whether or not five days is a suitable time to wait for necessary professional health care services remains a question. It is likely that those sorts of wait times contribute to Canada’s tenth-place ranking on timeliness of care. However, home-care wait times are being monitored in Ontario and are dropping.

Figure 2. Commonwealth Fund 2014 rankings of health systems performance

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The literature review conducted in Phase I of this study confirmed what policy decision makers hear anecdotally, e.g. that many different providers are responsible for prescribing or recommending home care, as well as coordinating and delivering the services. In practice, they are likely never to meet and may not communicate directly. Home care clients are assessed by CCAC care coordinators in the hospital or community for intake, and clients may self refer. They are then assigned to the caseload of a coordinator. Clients may also be reassigned to a different coordinator if care needs change (e.g. moving from community independence to complex) or if they move to another catchment area (e.g. an inter-CCAC transfer). A transfer can greatly affect the services available and a client’s eligibility to access them. Additionally, different CCACs have different models for assigning clients to care coordinators. CCAC care coordinators authorize the type of care (e.g. nursing care, PSW care, physical therapy, occupational therapy, or specialty nursing services) as well as the frequency and duration of visits. Home care agencies then decide the category of nurse (for nursing services), as well as the scheduling and timing of services. The CCAC may request specific scheduling but delivery of same is not guaranteed. Additionally, home care agencies determine the specific care activities to be done in the home, except when there are specific requirements such as intravenous antibiotics or wound care. Finally, at the point of care, the assigned providers may in turn delegate to another regulated or unregulated member of the team. The process by which the various care activities are assigned, delegated, supervised and/or monitored by RNs or RPNs, and across different providers, is unclear. As a result of the structure of home care in Ontario, it is quite typical for clients to be receiving home care services from multiple organizations, often with allied health providers coming from different agencies than the nursing and PSW teams.13 This complicates delegation, as a physiotherapist from one agency may delegate an exercise plan to a PSW from another agency for example. This requires the PSW supervisor to 9

also be present for the teaching, in order to be able to delegate to other PSWs on the team and facilitate ongoing monitoring. Why this matters to decision makers is because rigorous evidence shows that effective teamwork and communication are “essential for achieving high reliability systems” 14 and for both preventing and responding to adverse events.15 The communication chain is especially critical in high-risk industries such as nuclear power, commercial airlines and health care where the stakes are very high. Certainly the airline industry has learned from a generation of disastrous crashes to insist upon all employees following rigidly-enforced policies and rules around communication, team work, hand-off of tasks and the use of tools such as safety checklists and practical tools

Strict adherence to suitable standard operating procedures and normal checklists is an effective method to: •Prevent or mitigate crew errors, •Anticipate or manage operational threats, and thus, •Enhance ground and flight operations safety.

such as Airbus’ Golden Rules for cabin crews.16

Airbus, 2006

Flight crew training now emphasizes clear communication and how it will happen, identifies who is in charge while also empowering and requiring all team members to speak up, and mandates a sharply clear plan so that all team members agree on what will happen at each phase of a flight and how transitions will be managed between those phases. The results have been astounding, with commercial air travel having completely turned around its very spotty record since the 1970s. Effective communication is defined as “the accurate and unbroken transmission of information that results in understanding.”17 In the chain of hand-offs in home care, each additional team-to-team or person-to-person interface increases the possibility of miscommunication and error. Hard evidence is meager in the areas of hand-offs in home care, effectiveness of teaching, verification of competence, understanding of the services being delegated, and expected outcomes. However the research that has been done

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reveals some worrisome gaps that could jeopardize safety and frustrate both the recipients of care and those who deliver it.

The Home Care Patient Experience There is some evidence to support “the positive link between team-based care and patient satisfaction,”18 but the science is not all in and caution is warranted. For example, in a Toronto study of 28 triads each made up of a patient having multiple co-morbid chronic diseases, a family caregiver, and a physician, the patients expressed frustration with poor communication with and between health providers, and poor coordination among providers. Patients

Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Canadian Patient Safety Institute, 2011

observed that, “communication and coordination were further hindered by the rotation of medical trainees within the family health team.”19 Of interest, many of the physicians expressed similar sentiments, and also spoke to the challenge of filtering “communication from multiple sources.” The implications are serious because communication failures in health care are so clearly associated with adverse events across all health care settings.20,21 In a case review of 47 perinatal deaths in the United States for example, the Joint Commission on Accreditation of Healthcare Organizations concluded that “communication issues topped the list of identified root causes (72%), with more than one-half of the organizations (55%) citing organization culture as a barrier to effective communication and teamwork, i.e., hierarchy and intimidation, failure to function as a team, failure to follow the chain-of-communication,” as well as staff competency (47%) and orientation and training processes (40%).22

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Recipients of services assessed in a 2013 pan-Canadian study of home care safety (using Ontario data) complained about dealing with a “patchwork of services,” and variables identified as enabling adverse events included “inconsistencies in the way care is planned and delivered in home care,” and a “lack of integration of [home care] teams, lack of care coordination across healthcare sectors and failures in communication.” 23 These are precisely the sorts of issues identified in the Commonwealth Fund 2014 rankings. Health Quality Ontario (HQO) noted in its 2014 report that many Ontarians, “particularly those who are chronically ill or have complex needs,

Evidence reveals significant ongoing home care

“Many of the safety issues identified are related to system design, slow administrative processes, shortages of staff and equipment, and poor communication that lead to a lack of continuity and coordination of care.”

safety and efficiency concerns related to the kinds

Doran et al., 2013

depend on the different sectors of the health system to work well together.”24 HQO has begun to include measures of system integration in its annual reports.

of communication gaps identified by patients, their families and providers. The rate of adverse of events revealed in the national home care study was found to be “13% for 2008 and 2009. That rate expressed in clients per 1,000 client-days, was 0.858 in 2008 and 0.892 in 2009.”25 Adverse events most likely to result in an emergency department visit or hospital admission were found to be injuries from falls and other sources, and medication-related incidents.iii Importantly, “many of the [home care] safety issues identified are related to system design, slow administrative processes, shortages of staff and equipment, and poor communication that lead to a lack of continuity and coordination of care” — and 56% of

iii

“Clients with more co-morbid conditions, dependent Instrumental Activities of Daily Living and ADL, unstable disease, peripheral vascular disease, Parkinson, renal failure, polypharmacy, increased home care days, nursing service intensity in last seven days, and discharge from hospital within 30 days were at higher risk of adverse events” (from the home care safety study by Doran et al., 2013, p. 17).

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the adverse events were judged to be preventable. 26 Recommendations made by the researchers are listed in Appendix B.

Scope of Practice Issues In its recent national review of scope of practice, the Canadian Academy of Health Sciences spoke to optimal scope as, “achieving the most effective configuration of professional roles as determined by other health care professionals’ relative competencies.” 27 Implied is a thorough understanding of other providers’ scope of practice that seems to elude many professionals. Certainly the RPN—RN—nurse practitioner—physician continuum reveals significant overlap in scope of practice that might be contributing to longstanding confusion, competition and frustration. Enablers and barriers to optimal scope of practice identified by the Canadian Academy of Health Sciences are included in Appendix C. Nursing in Ontario is considered to be “one profession with two categories.”28 While they are co-regulated, the two categories are independent. Competencies falling under the regulated scope of practice of RNs and RPNs in Ontario is extensively described: The College of Nurses of Ontario (CNO) identifies 100 entry-to-practice competencies for RNs29 and 121 for RPNs.30 However, considerable overlap in the competencies for each group causes confusion and friction in differentiation between the two nursing categories. Without specific mention of RPNs, the Ontario RN competencies state that RNs must demonstrate “leadership in the coordination of health care by…delegating

iv

and

evaluating the performance of selected health care team members in carrying out

iv

The formal definition of delegation as used by the College of Nurses of Ontario refers to “a process by which a health care professional who has legal authority to perform a controlled act transfers that authority to an unauthorized person. There are 13 controlled acts in the Regulated Health Professions Act, 1991. By definition, a controlled act can cause harm if it is performed by an individual who is not competent.” See: http://www.cno.org/what-is-cno/regulation-and-legislation/legislation-governing-nursing/faq-delegation/

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delegated nursing activities.”31 The Ontario competencies also mandate RNs to know and support “the full scope of practice of team members.”32 The RPN competencies document suggests a decision tree (A guide to practice decisionmaking for the entry-level RPN)33 to clarify points of consultation and/or collaboration but does not require RPNs consult with RNs specifically. The competencies for RPNs do include assigning care and delegating controlled acts to unregulated care providers as appropriate; PSW supervisors in the community are predominantly RPNs. The CNO developed a framework linking client, nurse and environmental factors to facilitate “decision making related to care-provider assignment (which nursing category (Registered Nurse [RN] or Registered Practical Nurse [RPN]) to match with client needs), as well as the need for consultation and collaboration among care providers.” For example, Figures 3 and 4 portray continuums related to clients and the environment, with increasing complexity, unpredictability, risk and stability pointing to increasing need for RN consultation and collaboration. 34 Based on the three-factor framework, the CNO describes the conditions for fully autonomous RN or RPN practice on the one end of the spectrum, and the requirement for an RN to provide or direct care on the other. 35

Figure 3. College of Nurses of Ontario client continuum

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Figure 4. College of Nurses of Ontario environment continuum PSWs are unregulated care providers who are neither registered nor licensed by a regulatory body. As such, they have no legally defined scope of practice. The Ontario Personal Support Worker Association (OPSWA)36 has set out what it believes are core elements of PSW practice. However, as there is no standardized PSW curriculum or licensing exam, there is no way to ensure all PSWs have these competencies. Further complicating the situation is a lack of clarity and consistency around which tasks are core functions of PSWs (taught in educational programs), which tasks are client-specific and need to be taught and assigned, and which tasks require official delegation. The OPSWA core elements for PSW practice are contrasted in Table 2 with the CCAC description of community personal support and homemaking tasks37 found in the Client Services Policy Manual (see Appendix D). While there is considerable overlap in the tasks identified, the CCAC list is much more extensive. This may be because it also amounts to a job description and is not a higher-level statement on elements of scope. The OPSWA list is considerably shorter than regulated nursing descriptions of scope, is more task-focused, and also includes non-healthcare activities. The OPSWA also has developed 23 standards of practice intended to “support the PSW in providing safe, respectful and effective personal care to the public population in a dignified and ethical approach.” They “outline the expectations of the PSW and their responsibility in the delivery of care.”38 These standards include a range of topics including care related to patient populations (e.g. Alzheimer Care), body processes (e.g. Bowel Care and Skin Care) and technical procedures (e.g. Tube Feeding and Transfers.) 15

Table 2. Comparison of Ontario PSW Association scope of practice and CCAC personal support and homemaking tasks Ontario Personal Support Worker Association CCAC personal support and homemaking tasks practice elements Personal Support Tasks Can assist person(s) with activities of daily living such Personal hygiene activities and routine personal as feeding, lifts and transfers*, bathing, skin care, activities of living, including bathing, oral hygiene, oral hygiene, and toileting. hair and scalp care, skin and nail care, dressing, toileting, perineal hygiene care, positioning and transferring patients, assisting with mobility and with prosthetic and orthotic devices. Homemaking Tasks Can perform light housekeeping duties such as Housecleaning activities including cleaning weeping and mopping floors, vacuuming, washing equipment used for toileting assistance, washing dishes, and laundry. dishes, cleaning surfaces used in patient feeding and care, sweeping and mopping floors, vacuuming, disposing of garbage, laundry, menu planning, assisting with grocery list preparation and shopping, meal preparation, caring for child of the patient, and mailing cheques. Delegated and/or Taught and Assigned Tasks Can perform delegated tasks which have been With the approval of the CCAC, a PSW may carry delegated by [a regulated health provider] in out a range of approved care activities with and compliance with the [Regulated Health Professions for a client, provided that the care activities are Act] for which transfer of functional training has been assigned, delegated, supervised and/or taught in completed, such as insertion of a digit or instrument accordance applicable College Standards and into a body cavity, care or procedure under the Guidelines (see Appendix D. dermis and any task or skill needing a physician’s prescription. Additional Aspects of Care Must continuously observe person(s) and their PSWs are expected to follow a code of conduct in environments, and must report and document unsafe the provision of care that includes ethical conduct conditions and behavioral, physical, and/or cognitive and safety concerns. The code of conduct shall changes to an appropriate supervisor; i.e. family include guidelines with respect to: member, employer, care coordinator etc. · safe, competent and ethical care; · respectful treatment of Patients; · patient confidentiality and privacy; Must communicate and demonstrate basic · a patient’s right to choose; information to person(s) in relation to activities of · conflicts of interest; daily living, housekeeping and meal planning, in · solicitation; and accordance with pre-established Plan of Care. · informed consent. Must complete and maintain related records and documentation such as communication books and progress notes. *lifts and transfers are considered an added skill with a high risk of potential injury for clients and workers

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Structures and Processes of Delegation, Teaching & Assignment The structures and processes to support the ways RNs, RPNs and PSWs interact, delegate, assign and follow up are unclear. The CNO does provide guidelines for RNs and RPNs around teaching, assigning, delegating and supervising unregulated care providers.39 The tool lays out very specific expectations and accountabilities for nurses vis a vis assigning tasks to family members and to paid providers such as PSWs, and also for delegation of authority to perform controlled acts.v

Figure 5. College of Nurses of Ontario Decision tree: Making decisions about activities performed by unregulated care Figure 5 shows a decisionproviders (UCPs) making tree to support the initial steps in consideration of whether and when to assign or delegate elements of care to an unregulated care provider. While individual scopes of practice and the roster of expectations, responsibilities and accountabilities around care may be well laid out, the ways these play out in practice are much less clear. The level of assessment appropriate to each care provider is uncertain,

v

The College of Nurses of Ontario describes delegation in this context as “the transfer of authority to perform a controlled act procedure from a person who is authorized to perform the procedure to a person who is not otherwise authorized to perform the procedure.”

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and as depicted in Figure 6, there are multiple points of hand-off where communication has to be very clear to not drop details about client needs and supports.

Steps and factors in assignment of home care providers

Figure 6. Steps and factors in assignment of home care providers To deliver safe and effective services, each step in the chain of communication depicted in Figure 6 depends on clear communication and a human interpretation of patient needs based on what was reported during the previous step. In each case where home care is requested at the time of discharge from a hospital, there are at least four steps between the intention of the original person requesting home care services and the ultimate point of care. Within the home, further levels of assignment and delegation may be decided by physical and occupation therapists, RNs and RPNs. These decisions are individualized and are specific to the provider, client and environmental factors that may differ even across a single day. That level of decision-making has to rest with providers at the point of care. The number of transitions and hand-offs, and paucity of evidence about their impacts on outcomes represents a significant risk that should be managed as policy makers consider further expansion of home care in Ontario.

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Implications for Policy Decision Makers Home care is an attractive, feasible and affordable alternative to institution-based care and generally is more satisfying to patients than receiving care in an institution. However, the organization of home care in Ontario drives a number of safety, quality and user satisfaction concerns. These challenges may be exacerbated by the reality that home care is complex, often unpredictable, and demands providers normally to work alone in the homes of clients without immediate access to backup and support. 40 That reality creates a point of conflict given the volume of home care provided by RPNs and PSWs, whose practice should be aligned with stable patients in stable environments. There is a need to close gaps that place patients and providers at risk, and that jeopardize the effectiveness of home care: 

The process by which home care is authorized, organized, coordinated, delivered and evaluated entails numerous points of transition where human communication errors occur.



It is unclear whether the intention of the person originally authorizing home care for any given patient is appropriately matched by the actual services delivered.

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Care activities, including controlled acts, directed to a nurse by a coordinator in a remote office may subsequently be shared, assigned or delegated within the nursing team and/or to PSWs; delegation is always the decision of the regulated health professional at the point of care.

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There are numerous tools provided by regulators and others to aid in decisionmaking around assignment, delegation, teaching and supervision of tasks. However, the tools are embedded within documents that often are large and text dense. Their proper use depends on a thoughtful analysis of various sets of variables including a thorough understanding of scope of practice and a range of provider, patient and environmental factors. That purposeful decision-making process competes with speed and other imperatives at the point of care as providers juggle large caseloads. 19

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Whether, how, and how well these decision-making processes are utilized in the face of the decisions that need to be made in home care remains a significant gap. A better understanding of the gaps in these transitions and points of handoff of care hold the potential to close significant and persistent safety flashpoints documented in rigorous analyses of home care safety outcomes.

Next Steps Additional research is needed to examine the ways care is delegated in the home care setting. Very little is known about the provision of nursing care activities by unregulated care providers and the role that nurses play in delegating and supervising these care activities in home care. As care becomes more acute and complex, and as unregulated providers step outside their traditional roles, the risk for compromised care increases unless teaching, delegation and supervision by nurses is being provided effectively. Phase III of this study, already underway, will use primary research findings to evaluate how current Ontario legislation and policies are manifested in practice and how nurses and clients are affected by these structures of home-based nursing care. Those findings will be synthesized with the policy analysis, literature review and jurisdictional scan to generate recommendations for action. However, at this preliminary stage, the analysis points to potential actions in several areas that will need to be addressed to close the gaps identified in the jurisdictional scan and literature review: 

A better understanding of the relevant scopes of practice should be integrated into RN and RPN education, (e.g. innovative common curriculum or coeducation).



Consider barriers and enablers to optimal scope of practice identified by the Canadian Academy of Health Sciences, with particular reference to recommendations around collaborative, flexible and accountable multiprofessional models of care. 41

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

Delegation, assignment, teaching and supervision skills should be emphasized within RN and RPN undergraduate education, ongoing professional development programs, and employer-based orientation and continuing education programs — consistent with the Ministry’s commitment to more on-the-job training in its evolving transformation plan. 42



Streamlining processes by reducing the number of providers involved, and the number of points of transition could help to reduce communication errors. o Innovative technological solutions may accelerate efforts to reduce errors associated with the number of communications required to support effective patient care. o Safety may be strengthened by translating complex paper documents to mobile and interactive applications more readily and easily used by those assigning and providing home care. o Structural changes (e.g. co-location of coordinators and services providers) that strengthen transitions across and among providers, when patients are most vulnerable, hold promise to reduce frustration on the patient side and improve safety and effectiveness of the care delivered.43



Decision-making tools do exist that could be adapted for use and then shared in the Ontario home care context. For example: o The tool used to explain tiers of scopes of practice and tasks for various providers at Tresillian Family Care Centres in Sydney, Australia. 44 o The adapted colour-wheel concept developed by Boston-area based Barton Associates, which is a highly interactive, online tool that makes the examination of legislation and some practice boundaries across jurisdictions much easier.45

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Action on home care in the Ontario Health Action Plan should be aligned with recommendations of the pan-Canadian home care safety study and should take into account the Canadian Academy of Health Sciences’ challenge to optimize scope of practice in the interest of delivering better care to Ontarians. 21

Appendices Appendix A | Key Terms and Definitions Regulated Care Provider “A regulated health professional is a member of a health profession group that is regulated by government legislation which defines the scope of practice for the profession. The regulatory body, through self-regulation, establishes regulatory tools to ensure its members are competent, qualified and that they follow clearly defined standards of practice and ethical principles.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs Unregulated Care Provider “Unregulated care providers are paid care providers who are neither registered nor licensed by a regulatory body and who have no legally defined scope of practice.” CRNBC 2013 Assigning and Delegating to Unregulated care Providers “Unregulated care providers are members of the healthcare team who are not regulated by legislation but are accountable to their employers. UCPs have a scope of employment usually specified in a job description.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs Assignment “Assignment to UCPs occurs when the required task falls within the unregulated care provider’s role description and training, as defined by the employer or supervisor” CRNBC 2005 Delegating Tasks to Unregulated Care Providers “Allocation of clients or client care activities among care providers in order to meet client care needs.” CRNBC 2013 Assigning and Delegating to Unregulated care Providers “The allocation of clients or client care responsibilities or interventions that are within the provider’s scope of practice and/or scope of employment.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs Teaching Teaching involves providing instruction and determining that a UCP is competent to perform a procedure. CNO 2013 Working with unregulated care providers

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Delegation “Delegation to UCPs … occurs when the required task is performed primarily by nurses and is outside the role description and training of the unregulated care provider. Nurses delegate tasks - not functions – to UCPs.” CRNBC 2005 Delegating Tasks to Unregulated Care Providers “Sharing authority with other HCPs to provide a particular aspect of care. Delegation is client-specific… the UCP must not perform the delegated task with another client unless delegated.” CRNBC 2013 Assigning and Delegating to Unregulated care Providers “Transferring the responsibility to perform a function or intervention to a care provider who would not otherwise have the authority to perform it. Delegation does not involve transferring accountability for the outcome of the function or intervention although the delegate is responsible to successfully perform the intervention or task.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs Controlled Acts “Delegation is the transfer of authority to perform a controlled act procedure from a person who is authorized to perform the procedure to a person who is not otherwise authorized to perform the procedure.” CNO 2013 Working with unregulated care providers

Other Key Terms Task “A part of a client care function that has clearly defined limits and may be either a restricted activity or a nursing activity that is not a restricted activity.” CRNBC 2005 Delegating Tasks to Unregulated Care Providers

Function “A client care intervention that includes assessing and deciding to perform the function, planning and implementing the care and evaluating and managing the outcomes of care.” CRNBC 2005 Delegating Tasks to Unregulated Care Providers

Direct supervision “To be immediately present to guide or direct.” CRNBC 2013 Assigning and Delegating to Unregulated Care Providers

Indirect supervision “To supervise from a distance, not immediately present to guide or direct, but could be available within a specified time frame.” CRNBC 2013 Assigning and Delegating to Unregulated Care Providers 23

Activities of Daily Living “Activities that are identified when the need for the intervention, the response to the intervention, and the outcomes for performing the intervention have been established over time and, as a result, are predictable. ADLs would include those personal care activities that are well-established as a routine and may include, but are not limited to: eating, bathing, dressing, toileting, mobility, continence and communication.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs

Instrumental Activities of Daily Living “Activities that support independent living and may include but are not limited to: preparing meals, shopping for groceries or personal items, performing light or heavy housework and using a telephone.” CRNNS and CLPNNS 2012 Assignment and Delegation Guidelines for RNs and LPNs

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Appendix B | Recommendations of the pan-Canadian home care safety report Recommendations to address the safety concerns identified by the researchers:46

1. Organizations a) Offer unpaid caregivers training, ongoing support, counseling and health assessments; b) Implement policies and procedures to safely manage medication in the HC setting; and c) Assign to each home care client a cross-sector case manager with the authority and responsibility required to ensure the planning and delivery of a consistent quality of safe care.

2. Policymakers a) Develop standard competencies for home support workers; b) Explore opportunities for increased collaboration between home care and institutional care; c) Build integrated, interdisciplinary healthcare teams, involving clients and their caregivers, to ensure continuity of care delivery across all healthcare sectors, with particular attention to clients discharged from hospital to home care; d) Implement a common electronic chart accessible by all caregivers from all sectors to standardize communication among disciplines and across sectors and expand the use of electronic reporting and communication tools; e) Lift restrictions on the supply of portable oxygen tanks for clients with COPD; and f) Standardize medication packaging and equipment.

3. Researchers a) Develop and pilot a national set of reportable adverse events with common definitions, forms, and processes; and b) Develop and standardize policies specific to the process and timing for risk assessments and encourage the use of tools that are presently available in Canada, such as the Resident Assessment Instrument and its Clinical Assessment Protocols to assess and mitigate the risk of an adverse event occurring.

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Appendix C | Summary of barriers and enablers to optimal scope of practice identified by Canadian Academy of Health Sciences Barriers and enablers to optimal scope of practice identified by the Canadian Academy of Health Sciences are summarized in the following table.47

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Appendix D | CCAC Personal Support and Homemaking Tasks CCAC Personal Support and Homemaking Tasks Subject to any additions or deletions to the list of personal support and homemaking tasks set out in the Special Conditions of the Agreement, the Service Provider shall be capable and have the resources available to provide the following tasks:  Personal Support Tasks;  Homemaking Tasks; and  All activities that may be taught and that are supervised by a regulated health professional. Personal Support Tasks shall include,  personal hygiene activities and routine personal activities of living, including,  the following bathing activities: o assisting Patient to prepare for a bath or shower; assisting Patient with bath or shower; and performing a bed bath;  the following activities relating to oral hygiene: o assisting with and carrying out the cleaning of the Patient’s mouth area and dentures, if applicable; and o assisting with and carrying out the moisturising of the Patient’s lips;  the following activities relating to hair and scalp care: o assisting with and carrying out the washing of the Patient’s hair; brushing or combing the Patient’s hair; and drying and brushing Patient’s hair after washing;  the following activities relating to skin and nail care: o assisting with and carrying out the application of non-prescription skin lotion and powder to Patient; o assisting with and carrying out the shaving of Patient’s facial hair with an electric razor; and o filing fingernails and toenails; assisting Patient to put on and remove clothes;  the following activities relating to perineal hygiene: o assisting with and carrying out the washing, rinsing and drying of the Patient’s perineal area; o cleaning the skin around an indwelling catheter; and o preparing and assisting with Sitz bath;  the following activities relating to the elimination of waste material from the Patient’s body: o assisting Patient to use a toilet, commode, urinal or bedpan; o assisting with and carrying out changing of Patient’s personal hygiene products; 27

o attaching, securing and detaching urinary drainage bag; emptying of urinary drainage bag and stoma bag; measuring and recording amount of urinary output; obtaining a specimen from the Patient; and o applying a condom catheter to a Patient;  the following activities relating to the positioning and transferring of Patients: o assisting Patients to turn and reposition; turning and positioning Patients; o assisting with and carrying out the transfer of a Patient from one location to another; o assisting Patient with ambulation; and o assisting with and carrying out the application and removal of prostheses and orthotic devices. Homemaking Tasks shall include,  the following housecleaning activities: o cleaning sink, bath and shower after use by Service Provider Personnel for bathing of Patient; o emptying commode, urinal or bedpan after assisting Patient with toileting; o cleaning toilet, commode, urinal or bedpan after assisting Patient with toileting; o washing, drying and putting away dishes used to assist Patient with feeding; o cleaning surfaces of counters and appliances used to assist Patient with feeding; o cleaning kitchen and bathroom floors with wet mop, as necessary; dusting, mopping and vacuuming Patient’s primary living area; and o disposing of Patient’s garbage;  the following activities relating to Patient’s laundry: o washing laundry in washing machine at Service Delivery Location or laundromat; and drying laundry;  the following activities relating to shopping: o assisting with the preparation of a grocery list; and o shopping for groceries for a Patient in locations authorized by the CCAC;  the following activity relating to banking: o mailing cheques;  the following activities relating to meal preparation: o assisting with and carrying out the preparation of meals that take no longer than 30 minutes to prepare; o warming prepared foods; o dividing and storing prepared meals and food; o assisting with and carrying out the feeding of Patients; and o assisting with and carrying out the cleaning of Patient after a meal; 28


o planning menus; and  caring for the child of the Patient by carrying out, as applicable, any of the activities set out in SS Section 3.3.1(2) or 3.3.1(3), (the “Homemaking Tasks”). With the approval of the CCAC, the Service Provider shall carry out the following care activities with and for a Patient, provided that the care activities are assigned, delegated, supervised and/or taught in accordance applicable College Standards and Guidelines, including,  transferring Patient using transfer equipment;  using a transfer technique identified by a regulated health professional;  providing special mouth care as directed by a regulated health professional;  performing shallow oral suctioning on a Patient;  cueing, assisting with or carrying out range of motion exercises;  cleansing outer cannula for an established tracheostomy;  applying compression stockings to a Patient;  administering a commercially prepared enema to a Patient;  inserting a suppository into a Patient, if the suppository is part of an activity of daily living (not on a pro re nata basis);  assisting with and carrying out urine testing with test strips or similar technology on a Patient to determine sugar and acetone levels but excluding the interpretation of results;  assisting with the insertion, cleaning and removal of intermittent catheters;  administering tube feeding to a Patient;  measuring and recording fluid intake of a Patient;  after the Patient or Caregiver has prepared or premeasured the medication, assisting the Patient to take oral medication, if the Patient needs physical assistance to take the medication;  assisting a Patient with pre-loaded injections, excluding the administration of the injection itself  assisting with the administration of oxygen to a Patient;  assisting with and carrying out the administration of eye and ear drops to a Patient;  assisting with and carrying out the administration of inhalants to a Patient;  assisting Patient with and carrying out the application of medicated shampoos, medicated lotions, creams and ointments to the skin;  assisting a Patient with and carrying out the application of dry dressings;  assisting the Patient with exercise programs;  assisting the Patient with breathing exercises, including exercises relating to deep breathing, coughing and postural drainage;  performing Special Functions taught pursuant to SS Section 3.3.2;  any other activity taught by a regulated health professional;  assisting with the application of a medication patch; and 29

 assisting with blood glucose testing and recording. In addition to Personal Support Tasks and Homemaking Tasks, the Service Provider shall be capable of,  cueing the Patient with respect to any Personal Support and Homemaking Tasks and any other activity set out in the Patient’s Service Plan;  teaching the Patient and, if applicable, the Caregiver, techniques, activities and behaviour relating to the Care Delivery Plan; and  assessing and validating that the Patient and, if applicable, the Caregiver, have demonstrated their understanding and ability to carry out the acquired technique, activity and behaviour taught pursuant to SS Section 3.3.1(5)(b).

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Resources Permissions 1. 2.

Figure 1 is reproduced with permission of Statistics Canada Licence Grant. Figure 2 is reproduced with permission of The Commonwealth Fund.

References 1

Home Health Care Agencies. (2010). Benefits of home health care. (accessed January 21, 2014).

2

Sinha, M., & Bleakney, A. (2014). Receiving care at home. Spotlight on Canadians: Results from the General Social Survey. No. 002. Statistics Canada Catalogue no. 89-652-X p.1-16. http://www.statcan.gc.ca/pub/89-652-x/89-652-x2014002-eng.htm (Accessed January 17, 2015.)

3

Sinha, M., & Bleakney, A. (2014). Receiving care at home. Spotlight on Canadians: Results from the General Social Survey. No. 002. Statistics Canada Catalogue no. 89-652-X p.1-16. http://www.statcan.gc.ca/pub/89-652-x/89-652-x2014002-eng.htm (Accessed January 17, 2015.)

4

Source: Statistics Canada (2012), General social survey, cited in: Sinha, M. & Bleakney, A. (2014). Receiving care at home. Spotlight on Canadians: Results from the General Social Survey. No. 002. Statistics Canada Catalogue no. 89-652-X p.1-16. http://www.statcan.gc.ca/pub/89-652-x/89-652x2014002-eng.htm (Accessed January 17, 2015.)

5

Sinha, M., & Bleakney, A. (2014). Receiving care at home. Spotlight on Canadians: Results from the General Social Survey. No. 002. Statistics Canada Catalogue no. 89-652-X p.1-16. http://www.statcan.gc.ca/pub/89-652-x/89-652-x2014002-eng.htm (Accessed November 5, 2014)

6

College of Nurses of Ontario. (2014). Membership statistics highlights 2014. Toronto: Author. http://www.cno.org/Global/docs/general/43069_stats/43069_MembershipStatistics-Highlights.pdf

7

College of Nurses of Ontario. (2014). Membership statistics highlights 2014. Toronto: Author. http://www.cno.org/Global/docs/general/43069_stats/43069_MembershipStatistics-Highlights.pdf

8

Personal Support Network of Ontario. (2015). About PSNO. How long is the PSW program? Toronto: Author. Retrieved from http://www.psno.ca/faqs.html#how

9

Berta, W., Laporte, A., Deber, R., Baumann, A., & Gamble, B. (2013). The evolving role of health care aides in the long-term care and home and community care sector in Canada. Human Resources for Health, 11:25.

10

Ministry of Health and Long-Term Care. (2015). Patients first: Action plan for health care. Toronto: Author.

11

Davis, K., Stremikis., C., Schoen, C., & Squires, D. (2014). Mirror, mirror on the wall, 2014 Update: How the U.S. health care system compares internationally. New York: The Commonwealth Fund.

12

Health Quality Ontario. (2014). Measuring up. A yearly report on how Ontario’s health system is performing. Toronto: Author.

13

Tourangeau, A. (2014). Examining the impact of home care nurse staffing, work environments and collaboration on patient outcomes: A scoping review of the literature Toronto: Tourangeau Outcomes Research.

14

Canadian Patient Safety Institute. (2011). Canadian framework for teamwork and communication. Literature review, needs assessment, evaluation of training tools and expert consultations. Edmonton: Author. 31

http://www.patientsafetyinstitute.ca/English/toolsResources/teamworkCommunication/Documents/ Canadian%20Framework%20for%20Teamwork%20and%20Communications.pdf 15

Frank, J., & Brien, S. (Ed’s) on behalf of the Safety Competencies Steering Committee. (2008). The safety competencies: Enhancing patient safety across the health professions. Ottawa: Canadian Patient Safety Institute. http://www.patientsafetyinstitute.ca/English/toolsResources/safetyCompetencies/Documents/Safety %20Competencies.pdf

16

Airbus. (2006). Flight operations briefing notes. Standard operating procedures. Operating philosophy. Blagnac Cedex France: Author. Retrieved January 23, 2015 from: http://www.airbus.com/fileadmin/media_gallery/files/safety_library_items/AirbusSafetyLib_FLT_OPS_SOP_SEQ01.pdf

17

Canadian Patient Safety Institute. (2011). Canadian framework for teamwork and communication. Literature review, needs assessment, evaluation of training tools and expert consultations. Edmonton: Author. http://www.patientsafetyinstitute.ca/English/toolsResources/teamworkCommunication/Documents/ Canadian%20Framework%20for%20Teamwork%20and%20Communications.pdf (Accessed January 20, 2015.)

18

Wen, J., & Schulman, K. (2014). Can Team-based care improve patient satisfaction? A systematic review of randomized controlled trials. PLoS ONE 9(7): e100603. http://www.plosone.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pone.0100603&repr esentation=PDFdoi:10.1371/journal.pone.0100603 (Accessed January 15, 2015.) 19 Gill, A., Kuluski, K., Jaakkimainen, L., Naganathan, G., Upshur, R., & Wodchis, W. (2014). "Where do we go from here?" Health system frustrations expressed by patients with multimorbidity, their caregivers and family physicians. Healthcare Policy, 9(4): 73-89.doi:10.12927/hcpol.2014.23811 http://www.longwoods.com/content/23811 (Accessed January 30, 2015). 20

Baker, G. R., Norton, P. (2001). Making patients safer! Reducing error in Canadian healthcare. Healthcare Papers, 2(1): 10-31.

21

Canadian Patient Safety Institute. (2011). Teamwork and communication in health care. A literature review. Edmonton: Canadian Patient Safety Institute. http://www.patientsafetyinstitute.ca/English/toolsResources/teamworkCommunication/Documents/ Canadian%20Framework%20for%20Teamwork%20and%20Communications%20Lit%20Review.pdf (Accessed January 20, 2015).

22

Joint Commission on Accreditation of Healthcare Organizations. (2004). Sentinel event alert, 30. Oak Brook, IL: Author. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_30.PDF (Accessed January 4, 2015.)

23

Doran, D., Blais, R., Harrison, M., Hirdes, J., Baker, G.R., Lang, A., et al. (2013). Safety at home: A panCanadian home care safety study. Edmonton: Canadian Patient Safety Institute. http://www.patientsafetyinstitute.ca/english/research/commissionedresearch/safetyathome/docume nts/safety%20at%20home%20care.pdf

24

Health Quality Ontario. (2014). Measuring up. A yearly report on how Ontario’s health system is performing. Toronto: Author. p. 81

25

Doran, D., Blais, R., Harrison, M., Hirdes, J., Baker, G.R., Lang, A., et al. (2013). Safety at home: A panCanadian home care safety study. Edmonton: Canadian Patient Safety Institute. P. 11. http://www.patientsafetyinstitute.ca/english/research/commissionedresearch/safetyathome/docume nts/safety%20at%20home%20care.pdf (Accessed January 6, 2015.) 32


26

Doran, D., Blais, R., Harrison, M., Hirdes, J., Baker, G.R., Lang, A., et al. (2013). Safety at home: A panCanadian home care safety study. Edmonton: Canadian Patient Safety Institute. P. 11. http://www.patientsafetyinstitute.ca/english/research/commissionedresearch/safetyathome/docume nts/safety%20at%20home%20care.pdf (Accessed January 6, 2015.)

27

Nelson, S., Turnbull, J., Bainbridge, L., Caulfield, T., Hudon, G., Kendel, D., et al. (2014.) Optimizing scopes of practice: New models for a new health care system. Ottawa: Canadian Academy of Health Sciences. p. 22.

28

College of Nurses of Ontario. (2014). Entry-to-practice competencies for Ontario registered practical nurses. Toronto: Author. p. 3.

29

College of Nurses of Ontario. (2014). Competencies for entry-level registered nurse practice. Toronto: Author.

30

College of Nurses of Ontario. (2014). Entry-to-practice competencies for Ontario registered practical nurses. Toronto: Author.

31

College of Nurses of Ontario. (2014). Competencies for entry-level registered nurse practice. Toronto: Author. p. 9.

32

College of Nurses of Ontario. (2014). Competencies for entry-level registered nurse practice. Toronto: Author. p. 10.

33

College of Nurses of Ontario. (2014). Entry-to-practice competencies for Ontario registered practical nurses. Toronto: Author.

34

College of Nurses of Ontario. (2014). RN and RPN practice: The client, the nurse and the environment. Toronto: Author.

35

College of Nurses of Ontario. (2014). RN and RPN practice: The client, the nurse and the environment. Toronto: Author.

36

Ontario Personal Support Worker Association. (2015). Scope of practice for PSWs. Retrieved from http://opswa.webs.com/scope-of-practice (Accessed January 28, 2015.)

37

Community Care Access Centre. (2014). Schedule 3. Services schedule. Personal support and homemaking. Retrieved from http://healthcareathome.ca/serviceproviders/en/Documents/PDF%20CleansSept.%202,%202014/Schedule_3__Personal_Support_and_Homemaking_Services_Schedule_(Consolidated_Services_Version).pdf (Accessed February 22, 2015.)

38

Ontario Personal Support Worker Association. (2015). Standards of practice. Retrieved from http://opswa.webs.com/standards-of-practice (Accessed January 30, 2015.)

39

College of Nurses of Ontario. (2013). Practice guideline. Working with unregulated care providers. Toronto: Author.

40

Tourangeau, A. (2014). Examining the impact of home care nurse staffing, work environments and collaboration on patient outcomes: A scoping review of the literature Toronto: Tourangeau Outcomes Research.

41


42

Ministry of Health and Long-Term Care. (2015). Patients first. Action plan for health care. Toronto: Author. 33

43

Meadows, C., Camus, S., & Fraser, J. (in press). Transforming community access services through clientand family-centered homecare transitions. Canadian Journal of Nursing Leadership.

44

Tresillian Family Care Centres. (2015). Tresillian’s scope of practice. Sydney: Author. Retrieved from: http://www.tresillian.net/recruitment/scope-of-practice/child-and-family-health-nurse.html (Accessed January 6, 2015.)

45

Barton Associates. (2014). NP scope of practice laws. Boston: Author. http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/ (Accessed January 6, 2015.)

46

Doran, D., Blais, R., Harrison, M., Hirdes, J., Baker, G.R., Lang, A., et al. (2013). Safety at home: A panCanadian home care safety study. Edmonton: Canadian Patient Safety Institute. http://www.patientsafetyinstitute.ca/english/research/commissionedresearch/safetyathome/docume nts/safety%20at%20home%20care.pdf (Accessed January 6, 2015.)

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